ASTI'S REQUEST FOR ASSISTANCE

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Students and family members can request help for a student by using this form. ASTI staff members should use Aeries to make this kind of request.

Please note that options for group counseling may not start until the Spring 2022 semester due to available staffing.

Name of Student *

Student's grade level: *

What is your name? *

I am requesting support in the following area(s): *

Academics

Behavior

Social-Emotional Health

Attendance

Required

Why are you making this request? Check all that apply to the student. *

Needs support with technology

Low grades/lack of work completion

Missing credits

Issues related to depression

Withdrawn/Isolated from peers

Anxious/Worried

Basic Needs are not being met (food, shelter,clothing, hygiene)

Health Issues (vision, dental, stomach, headaches, etc.)

Often Tired

Speech difficulties

Possible substance use

Consistently Oppositional

Physical/verbal aggression

Poor impulse control or hyperactivity

Consistently inattentive

Peer Group Issues: Change in group or isolation

Often missing class

Excessive tardies

Other:

Required

Do any of the following sound appropriate for this student to try? *

Executive Functioning Skill-building Group: focuses on improving organization and planning

Check-in/Check-out: student checks in with a trusted staff member or older peer before and after school each day

Stress & Anxiety Management Group: focuses on practicing strategies to manage stress/anxiety

On-going individual counseling

On-going group counseling

None of the above

Other:

Required

Expected Outcome(s) *

Please describe your goal(s) for this student and the expected outcome of this request.

Any additional Information that will help us assess this student’s needs:

Contact information for referring party: Phone number or email address *

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